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Category Archives: Low Back Pain

The Mysteries of Low Back Pain!

Do you realize how complicated the low back region is when it comes to investigating the cause of low back pain (LBP)? There can be findings on an x-ray, MRI, or CT scan such as degenerative disk disease, arthritis, even bulging and/or herniated disks that have NOTHING to do with why the back hurts. Similarly, there are often other abnormal findings present in many of us who have NO low back pain whatsoever! Because of this seemingly paradoxical situation, we as clinicians must be careful not to over-diagnose based on the presence of these “abnormal findings” AND on the same hand, be careful not to titled-diagnose them as well.

Looking further into this interesting paradox, one study reported findings that support this point. Investigators examined 67 asymptomatic individuals who had NO prior history of low back pain and evaluated them using magnetic resonant imaging (MRI). They found 21 of the 67 (31%) had an identifiable disk and/or spinal canal abnormality (which is where the spinal cord and nerves nm). Seven years later, this same group of non-suffering individuals was once again contacted to see if they had developed any back problems within that time frame. The goal of the study was to determine if one could “predict” who might develop low back pain based on certain abnormal imaging findings in non-suffering subjects. A questionnaire was sent to each of these individuals, of which 50 completed and returned the questionnaire. A repeat MRI scan was performed on 31 of these subjects, and two neurologists and one orthopedic spine surgeon interpreted the MRI studies using a blended approach (without having knowledge about the subject’s symptoms or lack thereof). Each level was assessed for abnormalities including disk bulging/herniation and degeneration. Those who had initial abnormal findings were defined as “progressed” (worsened) if an increased severity of the original finding was evident or if additional or new spinal levels had become involved over the seven-year time span.

Of the 50 who returned the questionnaire, 29 (58%) had NO low back pain, while 21 had developed LBP. In the original group that had the MRI repeated seven years later, new MRI findings included the following: twelve remained “normal,” five had herniated disks, three had developed spinal stenosis, and one had “moderate” disk degeneration. Regarding radiating leg pain, four of the eight had abnormal findings originally, two of the eight had spinal stenosis, one had a disk protrusion, and one an “extruded” (“ruptured”) disk. In general, repeat MRI scans revealed a greater frequency of disk herniation, bulging, degeneration, and spinal stenosis compared to the original scans. Those with the longest duration of LBP did NOT have the greatest degree of abnormalities on the original scans. They concluded that the original MRI findings were NOT PREDICTIVE of the future development of LBP.

They summarized, ” … clinical correlation is essential to determine the importance of abnormalities on MR images.” These findings correlate well with other studies, such as 50% or more of all asymptomatic people HAVE bulging disks, and approximately 30% of us have herniated disks – WITHOUT PAIN. To be of diagnostic (clinical) value, the person MUST have signs and symptoms that agree with the imaging test, which is used to CONFIRM the diagnosis. Bottom line, If you have LBP, come see us, as we will evaluate and treat YOU, NOT your x-rays (or MRI) findings!

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for back pain, we would be honored to render our services.

Low Back Pain – When is it DANGEROUS to Wait?

Low back pain (LBP) typically results from relatively “benign” causes, meaning it’s usually safe to wait and try conservative / non-emergency care first. However, there are a handful of times when prompt medical emergency management is appropriate, and it’s important that everyone is aware of these uncommon but dangerous and sometimes deadly causes of LBP, hence the purpose of this article.

“Red flags” trace back to the 1980s and 1990s, so this is not a “new” topic. In fact, guidelines for the care of LBP that have been published around the world ALL commonly state the anyone exhibiting these “red flags” needs to be promptly diagnosed and referred for emergent care. The common conditions cited in these guidelines include (but are not limited to):
I) Cancer, 2) Cauda equine syndrome, 3) Infection, 4) Fracture. The patient’s history can sometimes uncover suspicion of these four conditions BETTER than a routine physical examination, though a definitive diagnosis is usually made only after special diagnostic tests have been-completed including (but not limited to) imaging (x-ray, MRI, CT, PET scans), blood tests, bone scans, and more.

I) Cancer: a) Past history of cancer. b) Unexplained weight loss(>10 kg within 6 months). c) Age over 50 or under age 18. d) Failure to respond to usual care (therapy). e) Pain that persists for four to six weeks. f) Night pain or pain at rest.

Infection: a) Persistent fever (>l00.4° F). b) Current/recent URI (upper respiratory tract infection like pneumonia) or UTI (urinary tract or kidney infection). b) History of intravenous drug abuse. c) Severe back pain. d) Lumbar spine surgery within the past year. e) Recent bacterial infection (cellulitis or persistent wound – e.g., a decubitus ulcer or “pressure sore” in the low back region). f) Immunocompromised states such as those caused by systemic corticosteroids, organ transplant medications, diabetes mellitus, human immunodeficiency virus (HIV).

Cauda Equina Syndrome: a) Urinary incontinence or retention. b) Saddle anesthesia. c) Anal sphincter tone decrease or fecal incontinence. d) Bilateral lower extremity weakness or numbness. e) Progressive neurologic deficit or loss – major muscle weakness or sensory deficit.

Fracture: a) Prolonged corticosteroid use. b) Age >70. c) History of Osteoporosis (poor bone density). d) Mild trauma over age 50. e) Major trauma at any age (such as a fall).

Another red flag is an Abdominal Aortic Aneurism. Signs include: a) Abdominal pulsations. b) Hardening of the arteries (atherosclerotic vascular disease). c) Pain at rest or night time pain. d) Age >60.

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for back pain, we would be honored to render our services.

Is Sitting BAD for My Back?

A major manufacturer of workstations reports that 86% of work computer users have to sit all day, and when they do rise from sitting, more than half (56%) use food as the excuse to get up and move. In addition to sitting at work, for meals, and commuting to/from work, 36% sit another one to two hours watching TV, I 0% sit one to two hours for gaming, 25% sit one to two hours for reading/lounging, and 29% use their home computer for one to two hours. In summary, the average American sits for thirteen hours a day and sleep for eight hours. That’s a total of 21 hours a day off their feet!

The manufacturer’s survey also notes 93% of work computer users don’t !mow what “Sitting Disease” is but 74% believe that sitting too much can lead to an early death. “Sitting Disease” represents the ill-effects of an overly sedentary lifestyle and includes conditions like “metabolic syndrome” (obesity and diabetes), which is rapidly becoming more prevalent, especially in the young – even in adolescence and teenagers! Recently, the American Medical Association (AMA) adopted a policy encouraging employers, employees, and others to sit less citing the many risks associated with sitting including (but not limited to): diabetes, cancer, obesity, and cardiovascular disease. Standing is SO MUCH BETTER as it burns more calories than sitting, tones muscles, improves posture, increases blood flow, reduces blood sugar, and improves metabolism. Standing is frequently overlooked as “an exercise” and it’s both simple and easy to do!

So, what about the low back and sitting? You guessed it – sitting is hard on the back! The pressure inside of our disks, those “shock absorbers” that lie between each vertebra in our spine (22 disks in total) is higher when we sit compared with simply standing or lying down. It’s estimated that when we lay down, the pressure on our disks is the lowest at 25mm. When lying on one side, it increases to 75mm, standing increases disk pressure to I00mm, and bending over from standing pushes disk pressure to 220mm. When we sit with good posture, our disk pressure may reach 140mm but that can increase to 190mm with poor posture. To help relieve the pressure on our disks, experts recommend: I) Getting up periodically and standing; 2) Sitting back in your chair and avoiding slouched positions; 3) Placing a lumbar roll (about the size of your forearm) behind the low back and chair/car seat; and 4) Changing your position frequently when sitting.

Because certain low back conditions “favor” one position over another, these “rules” may need modification. For example, most herniated disk patients prefer low back extension while bending over or slouching hurts. In those with lumbar sprain/strains, bending forwards usually feels good and extension hurts. Modifying your position to the one that is most comfortable is perhaps the best advice.

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for back pain, we would be honored to render our services.